Persistent anterior chamber silicone oil and myopia

A 60-year-old male experienced a marked unilateral myopic shift of 20 D following attempted removal of intravitreal heavy silicone oil (HSO) used in the treatment of inferior proliferative vitreous retinopathy following retinal detachment. Examination revealed HSO adherent to the corneal endothelium forming a convex interface with the aqueous, obscuring the entire pupil, which required surgical intervention to restore visual acuity. This case highlights the potential ocular complications associated with silicone oil migration into the anterior chamber, which include corneal endothelial decompensation and a significant increase in myopia.

Long-term graft survival in patients with flexible open-loop anterior chamber intraocular lenses

Purpose. To evaluate the long-term graft survival in patients with flexible open-loop anterior chamber intraocular lenses (AC IOL). Methods. We retrospectively reviewed the records of patients with aphakic/pseudophakic bullous keratopathy who underwent penetrating keratoplasty and flexible open-loop AC IOL implantation in our institution from 1983 to 1988. Results. 79 eyes from 77 patients were included in the study. Mean follow-up was 50 months (range 1 to 123 months). At last follow-up 61 eyes (77.2%) had clear grafts. Among them, the visual acuity was = 20/40 in 14 eyes (23.0%), 20/50-20/100 in 22 eyes (36.1%), 20/200-20/400 in 9 eyes (14.8%) and = CF in 16 (26.2%). Increment of glaucoma medications and/or glaucoma surgery was the most frequent complication (37 eyes, 46,8%). Cystoid macular edema was newly diagnosed in 10 eyes (12.7%). Conclusions. Flexible, open-loop anterior chamber lens are a viable option in the treatment of patients with aphakic or pseudophakic bullous keratopathy undergoing penetrating keratoplasty.

Long-term graft survival in patients with flexible open-loop anterior- chamber intraocular lenses

Purpose. To evaluate the long-term graft survival and complications of flexible, open-loop anterior-chamber intraocular lenses in patients with penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy. Methods. We reviewed charts of all consecutive patients who underwent penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy combined with implantation of a flexible, open-loop, anterior-chamber intraocular lens at our institution between 1983 and 1988. One-hundred one eyes of 99 patients were evaluated. Graft-survival rates were calculated by using the Kaplan-Meier actuarial method. Results. Mean follow-up was 49.8 months (range. 1-144). The probability of graft survival at 1, 2, 4, 6, and 8 years was 93, 87, 78, 65, and 65%, respectively. A total of 25 (24.8%) grafts failed. Progressive corneal edema without signs of rejection was the most common finding in patients with failed grafts (10 eyes, 40%). The most frequent complication observed was newly diagnosed or worsening of preexisting glaucoma (46 eyes, 45.5%). Conclusions. Our long-term results support flexible, open-loop anterior-chamber intraocular lenses as a reasonable option, at the time of penetrating keratoplasty, in patients with pseudophakic and aphakic bullous keratopathy.

Inter-observer agreement in evaluating the anterior chamber angle by ultrasound biomicroscopy

Purpose. To determine the agreement between observers in estimating the configuration of the human anterior chamber angle (ACA) using ultrasound biomicroscopy (UBM). Methods. Two masked clinicians used UBM images to estimate, in 41 eyes, the configuration of the ACA, especially (1) the position of contact between the peripheral iris and the inside of the eye wall, (2) the angularity of the approach to the ACA, and (3) the curvature of the peripheral iris. Agreement between observers was evaluated by the kappa statistic. Results. Inter-observer agreement in assessing the iris insertion (kappa = 0.79), angular width (Kappa = 0.95), and the peripheral iris curvature (kappa = 0.84) was high. Conclusions. The agreement between observers in evaluating the anterior chamber angle configuration by UBM was excellent.

Increasing the size of a small peripheral iridotomy widens the anterior chamber angle:An ultrasound biomicroscopy study

Purpose: A peripheral iridotomy (PI) is the treatment of choice for pupillary block. In this study we investigated the effect of enlarging the size of a small PI on the anterior chamber angle in patients with angle closure using ultrasound biomicroscopy (UBM). Patients and Methods: Patients who had been treated with laser peripheral iridotomy for angle closure and were identified to have a small patent PI (<100 µm) with still appositionally closed anterior chamber angle were selected prospectively. The anterior chamber angle was assessed using UBM. The angle opening distance 500 µm from the scleral spur (AOD500) as well as the anterior and posterior chamber depth (ACD and PCD) 1000 µm from the scleral spur was measured. In addition, the ACD/PCD ratio was calculated. Afterwards, the PI was enlarged using an Nd: YAG laser and the UBM measurements were repeated as described above. Results: Six eyes of six patients were examined. After the enlargement of the PI the average AOD500 increased from 109 µm (±36) to 147 µm (±40) (p

Intraobserver and interobserver agreement in evaluating the anterior chamber angle configuration by ultrasound biomicroscopy

Purpose: To determine the intra- and interobserver agreement in assessing the configuration of the human anterior chamber angle using ultrasound biomicroscopy (UBM). Methods: Two masked clinicians used ubm images to estimate, in 41 eyes, (a) the position of contact between the peripheral iris and the inside of the eye wall, (b) the angular size of the anterior chamber angle (ACA), and (c) the curvature of the peripheral iris. Both observers, masked to the previous results, examined the same images in a second session. Agreement was evaluated using the unweighted ? statistic. Results: Intraobserver agreement in assessing the iris insertion, angular width, and the iris curvature was high (range of ? values, 0.83-0.92). Interobserver agreement in evaluating the level of iris insertion (? = 0.79), the angular width (? = 0.95), and the iris curvature (? = 0.84) was also high. Conclusion: The agreement within the same observer and between observers in evaluating the ACA configuration by UBM was excellent.

Determinants and two-year change in anterior chamber angle width in a Chinese population

Objective: To study the population distribution and longitudinal changes in anterior chamber angle width and its determinants among Chinese adults. Design: Prospective cohort, population-based study. Participants: Persons aged 35 years or more residing in Guangzhou, China, who had not previously undergone incisional or laser eye surgery. Methods: In December 2008 and December 2010, all subjects underwent automated keratometry, and a random 50% sample had anterior segment optical coherence tomography with measurement of angle-opening distance at 500 μm (AOD500), angle recess area (ARA), iris thickness at 750 μm (IT750), iris curvature, pupil diameter, corneal thickness, anterior chamber width (ACW), lens vault (LV), and lens thickness (LT) and measurement of axial length (AL) and anterior chamber depth (ACD) by partial coherence laser interferometry. Main Outcome Measures: Baseline and 2-year change in AOD500 and ARA in the right eye. Results: A total of 745 subjects were present for full biometric testing in both 2008 and 2010 (mean age at baseline, 52.2 years; standard deviation [SD], 11.5 years; 53.7% were female). Test completion rates in 2010 varied from 77.3% (AOD500: 576/745) to 100% (AL). Mean AOD500 decreased from 0.25 mm (SD, 0.13 mm) in 2008 to 0.21 mm (SD, 13 mm) in 2010 (difference, -0.04; 95% confidence interval [CI], -0.05 to -0.03). The ARA decreased from 21.5±3.73 10^-2 mm² to 21.0±3.64 10 ^-2 mm² (difference, -0.46; 95% CI, -0.52 to -0.41). The decrease in both was most pronounced among younger subjects and those with baseline AOD500 in the widest quartile at baseline. The following baseline variables were significantly associated with a greater 2-year decrease in both AOD500 and ARA: deeper ACD, steeper iris curvature, smaller LV, greater ARA, and greater AOD500. By using simple regression models, we could explain 52% to 58% and 93% of variation in baseline AOD500 and ARA, respectively, but only 27% and 16% of variation in 2-year change in AOD500 and ARA, respectively. Conclusions: Younger persons and those with the least crowded anterior chambers at baseline have the largest 2-year decreases in AOD500 and ARA. The ability to predict change in angle width based on demographic and biometric factors is relatively poor, which may have implications for screening. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. © 2012 American Academy of Ophthalmology.

A proposed simple method for measurement in the anterior chamber angle: biometric gonioscopy

OBJECTIVE:

To design a system of gonioscopy that will allow greater interobserver reliability and more clearly defined screening cutoffs for angle closure than current systems while being simple to teach and technologically appropriate for use in rural Asia, where the prevalence of angle-closure glaucoma is highest.

DESIGN:

Clinic-based validation and interobserver reliability trial.

PARTICIPANTS:

Study 1: 21 patients 18 years of age and older recruited from a university-based specialty glaucoma clinic; study 2: 32 patients 18 years of age and older recruited from the same clinic.

INTERVENTION:

In study 1, all participants underwent conventional gonioscopy by an experienced observer (GLS) using the Spaeth system and in the same eye also underwent Scheimpflug photography, ultrasonographic measurement of anterior chamber depth and axial length, automatic refraction, and biometric gonioscopy with measurement of the distance from iris insertion to Schwalbe's line using a reticule based in the slit-lamp ocular. In study 2, all participants underwent both conventional gonioscopy and biometric gonioscopy by an experienced gonioscopist (NGC) and a medical student with no previous training in gonioscopy (JK).

MAIN OUTCOME MEASURES:

Study 1: The association between biometric gonioscopy and conventional gonioscopy, Scheimpflug photography, and other factors known to correlate with the configuration of the angle. Study 2: Interobserver agreement using biometric gonioscopy compared to that obtained with conventional gonioscopy.

RESULTS:

In study 1, there was an independent, monotonic, statistically significant relationship between biometric gonioscopy and both Spaeth angle (P = 0.001, t test) and Spaeth insertion (P = 0.008, t test) grades. Biometric gonioscopy correctly identified six of six patients with occludable angles according to Spaeth criteria. Biometric gonioscopic grade was also significantly associated with the anterior chamber angle as measured by Scheimpflug photography (P = 0.005, t test). In study 2, the intraclass correlation coefficient between graders for biometric gonioscopy (0.97) was higher than for Spaeth angle grade (0.72) or Spaeth insertion grade (0.84).

CONCLUSION:

Biometric gonioscopy correlates well with other measures of the anterior chamber angle, shows a higher degree of interobserver reliability than conventional gonioscopy, and can readily be learned by an inexperienced observer.

Biometric gonioscopy and the effects of age, race, and sex on the anterior chamber angle.

AIM:

To utilise a novel method for making measurements in the anterior chamber in order to compare the anterior chamber angles of people of European, African, and east Asian descent aged 40 years and over.

METHODS:

A cross sectional study on 15 people of each sex from each decade from the 40s to the 70s, from each of three racial groups-black, white, and Chinese Singaporeans. Biometric gonioscopy (BG) utilises a slit lamp mounted reticule to make measurements from the apparent iris insertion to Schwalbe's line through a Goldmann one mirror goniolens. The main outcome measures were BG measurements of the anterior chamber angle as detailed above.

RESULTS:

There was no significant difference in angle measurement between black, white, and Chinese races in this study. However, at younger ages people of Chinese race appeared to have deeper angles than white or black people, whereas the angles of older Chinese were significantly narrower (p = 0.004 for the difference in slope of BG by age between Chinese and both black and white people).

CONCLUSION:

The failure to detect a difference in angle measurements between these groups was surprising, given the much higher prevalence of angle closure among Chinese. It appears that the overall apparent similarity of BG means between Chinese and Western populations may mask very different trends with age. The apparently more rapid decline in angle width measurements with age among Chinese may be due to the higher prevalence of cataract or "creeping angle closure." However, longitudinal inferences from cross sectional data are problematic, and this may represent a cohort phenomenon caused by the increasing prevalence of myopia in the younger Singaporean population.

Age, gender, biometry, refractive error, and the anterior chamber angle among Alaskan Eskimos.

BACKGROUND:

The prevalence of angle-closure glaucoma (ACG) is greater for Eskimos/Inuit than it is for any other ethnic group in the world. Although it has been suggested that this prevalence may be due to a population tendency toward shallower anterior chamber angles, available evidence for other populations such as Chinese with high rates of ACG has not consistently demonstrated such a tendency.

METHODS:

A reticule, slit-lamp, and standard Goldmann one-mirror goniolens were used to make measurements in the anterior chamber (AC) angle according to a previously reported protocol for biometric gonioscopy (BG) (Ophthalmology 1999;106:2161-7). Measurements were made in all four quadrants of one eye among 133 phakic Alaskan Eskimos aged 40 years and older. Automatic refraction, dilated examination of the anterior segment and optic nerve, and A-scan measurements of AC depth, lens thickness, and axial length were also carried out for all subjects.

RESULTS:

Both central and peripheral AC measurements for the Eskimo subjects were significantly lower than those previously reported by us for Chinese, blacks, and whites under the identical protocol. Eskimos also seemed to have somewhat more hyperopia. There were no differences in biometric measurements between men and women in this Eskimo population. Angle measurements by BG seemed to decline more rapidly over life among Eskimos and Chinese than blacks or whites. Although there was a significant apparent decrease in AC depth, increase in lens thickness, and increase in hyperopia with age among Eskimos, all of these trends seemed to reverse in the seventh decade and beyond.

CONCLUSIONS:

Eskimos do seem to have shallower ACs than do other racial groups. Measurements of the AC angle seem to decline more rapidly over life among Eskimos than among blacks or whites, a phenomenon also observed by us among Chinese, another group with high ACG prevalence. This apparent more rapid decline may be due to a cohort effect with higher prevalence of myopia and resulting wider angles among younger Eskimos and Chinese.

A method of measuring anterior chamber volume using the anterior segment optical coherence tomographer and specialized software.

PURPOSE: To describe and evaluate a new method for measuring anterior chamber volume (ACV). DESIGN: Observational case series. METHODS: The authors measured ACV using the anterior chamber (AC) optical coherence tomographer (OCT) and applied image-processing software developed by them. Repeatability was evaluated. The ACV was measured in patient groups with normal ACs, shallow ACs, and deep ACs. The volume difference before and after laser peripheral iridotomy (LPI) was analyzed for the shallow and deep groups. RESULTS: Coefficients of repeatability for intraoperator, interoperator, and interimage measurements were 0.406%, 0.958%, and 0.851%, respectively. The limits of agreement for intraoperator and interoperator measurement were -0.911 microl to 1.343 microl and -7.875 microl to -2.463 microl, respectively. There were significant ACV differences in normal, shallow, and deep AC eyes (P < .001) and before and after LPI in shallow AC (P < .001) and deep AC (P = .008) eyes. CONCLUSIONS: The ACV values obtained by this method were repeatable and in accord with clinical observation.

Comparison of techniques for measuring anterior chamber depth:Orbscan imaging, Smith's technique, and van Herick's method

Background Evaluation of anterior chamber depth (ACD) can potentially identify those patients at risk of angle-closure glaucoma. We aimed to: compare van Herick’s limbal chamber depth (LCDvh) grades with LCDorb grades calculated from the Orbscan anterior chamber angle values; determine Smith’s technique ACD and compare to Orbscan ACD; and calculate a constant for Smith’s technique using Orbscan ACD. Methods Eighty participants free from eye disease underwent LCDvh grading, Smith’s technique ACD, and Orbscan anterior chamber angle and ACD measurement. Results LCDvh overestimated grades by a mean of 0.25 (coefficient of repeatability [CR] 1.59) compared to LCDorb. Smith’s technique (constant 1.40 and 1.31) overestimated ACD by a mean of 0.33 mm (CR 0.82) and 0.12 mm (CR 0.79) respectively, compared to Orbscan. Using linear regression, we determined a constant of 1.22 for Smith’s slit-length method. Conclusions Smith’s technique (constant 1.31) provided an ACD that is closer to that found with Orbscan compared to a constant of 1.40 or LCDvh. Our findings also suggest that Smith’s technique would produce values closer to that obtained with Orbscan by using a constant of 1.22.

Phacoemulsification combined with posterior capsulorhexis and anterior vitrectomy in the management of malignant glaucoma in phakic eyes

Purpose: To describe sequential phacoemulsification-intraocular lens (IOL) implantation-posterior capsulorhexis-anterior vitrectomy in the management of phakic malignant glaucoma. Methods: Twenty consecutive patients (25 eyes) with phakic malignant glaucoma were enrolled at the Zhongshan Ophthalmic Center, Sun Yat-sen University. All patients underwent phacoemulsification, IOL implantation and posterior capsulorhexis together with anterior vitrectomy via a clear corneal paracentesis. Visual acuity, intraocular pressure (IOP), anterior chamber depth (ACD), surgical complications and medications required after the surgery were recorded. Results: After surgery, the mean LogMAR visual acuity and ACD increased significantly (visual acuity from -1.56 ± 1.17 to -0.54 ± 0.81, p < 0.001; ACD from 0.367 ± 0.397 mm to 2.390 ± 0.575 mm, p < 0.001), and mean IOP decreased significantly (from 39.6 ± 10.6 mm Hg to 14.5 ± 4.1 mmHg, p < 0.001). No serious perioperative complications occurred, and only five eyes required topical glaucoma medications after surgery. Conclusion: Combined phacoemulsification-IOL implantation-posterior capsulorhexis-anterior vitrectomy surgery is a safe and effective method for treating patients with phakic malignant glaucoma. © 2012 The Authors. Acta Ophthalmologica © 2012 Acta Ophthalmologica Scandinavica Foundation.

Dark room provocative test and extent of angle closure: an anterior segment OCT study.

PURPOSE: To clarify the risk parameters measured by anterior segment optical coherence tomography (AS-OCT) for elevated intraocular pressures (IOP) provoked by the darkroom test and to provide recommendations for its clinical usage. METHODS: Subjects aged >40 years and whose peripheral anterior chambers were ≤1/4 corneal thickness were recruited. The anterior segment of the eye was imaged in sitting position and under both light and dark conditions and biometry was performed using anterior segment optical coherence tomography. The analyzed parameters were: (1) central anterior chamber depth (ACD); (2) anterior chamber width; (3) pupil diameter; (4) iris curvature; (5) lens thickness; and (6) number of meridians with closed angles (NCA). Then the darkroom test was performed and a positive provocative test result was defined as a rise in IOP ≥8 mm Hg after the test. Statistical analyses included: (1) the difference in parameters between positive and negative eyes; (2) the association between posttest IOP and the parameters; and (3) the difference in parameters between the 2 eyes in subjects with the asymmetric results. RESULTS: A total of 70 subjects were recruited. ACD (P=0.022), NCA in light (P<0.001), and NCA in dark (P<0.001) were different significantly between eyes with positive and negative results. There was a strong association between NCA in dark (r=0.755, P<0.001) and the posttest IOP. Among subjects with asymmetric results between the 2 eyes, the ACD was shallower and the lens thickness was larger in the positive eye. CONCLUSIONS: The posttest IOP is determined by the extent of functionally closed angles in the dark. The test may be useful in the early diagnosis of primary angle closure. At the same time, angle configuration should be evaluated to remove false positive result.